Clinical Nurse Reviewer RN or LPN - Fully Remote
Location: San Diego
Posted on: January 16, 2022
Clinical Nurse Reviewer
- Are you an experienced Clinical Nurse Reviewer looking for a
- Do you value care management and quality improvement?
- Are you motivated, energetic, and excited to become part of the
If so, you might be our next new team member!
Who We Need
Utilizes clinical expertise for the review of medical records
against appropriate criteria in conjunction with contract
requirements, critical thinking and decision making skills to
determine medical appropriateness, while maintaining production
goals and QA standards. Ensures day-to-day processes are conducted
in accordance with NCQA, URAC and other regulatory standards.
Kepro is a rapidly growing national quality improvement and care
management organization. We work to ensure that over 20 million
people receive the right care, at the right time, in the right
People Focused. Mission Driven.
Shape the future of healthcare with us. We are mission driven to
improve lives through healthcare quality and clinical
We do this through our people.
At Kepro, you can do meaningful work that makes a real difference
for the lives of individuals across the country. We are an
organization that cares deeply about our employees and we provide
the training and support to do the best work of your career.
Benefits are a key component of your rewards package at Kepro.
These benefits are designed to provide you and your family
additional protection, security, and support for both your career
and your life away from work. They are comprehensive and fit a
variety of needs and situations. Our benefits include comprehensive
health plans, paid time off, retirement savings, corporate
wellness, educational assistance, corporate discounts and more.
What You'll Do
- Reviews and interprets patient records and compares against
criteria to determine medical necessity and appropriateness of
care; determines if the medical record documentation supports the
need for services.
- Determines approval or initiates a referral to the physician
consultant and processes physician consultant decisions ensuring
reason for the denial is described in sufficient detail on
- Abstracts review related data/information accurately and timely
on appropriate review tool by the appropriate means. Accurate and
timely submission of all administrative and review related
documents to appropriate parties.
- Performs ongoing reassessment of review process to offer
opportunities for improvement and/or change.
- Foster positive and professional relationships and act as
liaison with internal and external customers to ensure effective
working relationships and team building in order to facilitate the
- Responsible for attending training and scheduled meetings and
for maintenance and use of current/updated information for
- Maintains medical records confidentiality at all times through
proper use of computer passwords, maintenance of secured files,
adherence to HIPAA polices.
- Utilizes proper telephone etiquette and judicious use of other
verbal and written communications, following KEPRO policies,
procedures and guidelines
- Actively cross-trains to perform duties of other contracts
within the KEPRO network to provide a flexible workforce to meet
The list of accountabilities is not intended to be all-inclusive
and may be expanded to include other duties that management may
deem necessary from time to time.
What you'll need:
- Active unrestricted LPN, RN, Social Worker or other applicable
State and/or Compact State clinical license per contract
- Graduation from an accredited Diploma, Associates Degree or
Bachelor's Degree Program.
- Minimum two years of clinical experience in an acute or
med-surgical environment required.
- Minimum of one year UR and/or Prior Authorization or related
- For BH Programs: Minimum 3 years direct behavioral/mental
health experience in a clinical setting or other applicable State
and/or Compact State clinical experience or license per contract
Knowledge, Skills, Abilities
- Knowledge of InterQual criteria strongly preferred.
- Knowledge of current NCQA/URAC standards strongly
- Medical record abstracting skills required.
- Knowledge of the organization of medical records, medical
terminology, and disease process required.
- Strong clinical assessment and critical thinking skills
- Excellent verbal and written communication skills
- Ability to work in a team environment.
- Flexibility and strong organizational skills needed.
- Must be proficient in Microsoft Office and internet/web
We know your time is valuable and we thank you in advance for
applying for this position. Due to the high volume of applicants we
receive, only those who are chosen to advance in our interview
process will be contacted. We sincerely appreciate your interest in
Kepro and invite you to apply to future openings that may be of
interest. Best of luck in your search!
- The Kepro Talent Acquisition Team
Mental And Physical Requirements
The physical demands described here are representative of those
that must be met by an employee to successfully perform the
essential functions of this job. Reasonable accommodations will be
made as required by law in an attempt to enable an individual with
a disability to perform the essential functions of this job. While
performing the duties of this job, the employee is regularly
required to sit for prolonged periods of time; key and/or control
objects; interact extensively with internal and external customers;
occasionally lift and/or move objects weighing up to 10 pounds; and
occasionally travel within the state.
EOE AA M/F/Vet/Disability
Kepro is an Equal Opportunity Employer. All qualified applicants
will receive consideration for employment without regard to race,
color, religion, sex, sexual orientation, gender identity, national
origin, disability, or status as a protected veteran.
Keywords: Kepro, San Diego , Clinical Nurse Reviewer RN or LPN - Fully Remote, Healthcare , San Diego, California
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